Early in my new novel, Big Brother, the narrator meets her older brother at the airport and initially fails to recognize him: he’s gained hundreds of pounds.

“What happened to Uncle Edison?” her stepdaughter asks quietly the first night of the brother’s visit. “Is he sick?”

“According to the latest thinking on the subject,” the narrator replies, “yes.” She notes, “Though I was personally unsure how labeling obesity an ‘illness’ got anyone anywhere.” Now it’s official—the American Medical Association has classified obesity as a disease—but it’s still not clear this gets anyone anywhere.

My older brother was morbidly obese. His case history exemplifies the difficulty of determining whether obesity is a disease or is merely a risk factor for diseases. After a cascade of medical crises, he landed in the hospital after carbon dioxide poisoning from sleep apnea (aggravated by his weight). He caught an infection, which his struggling circulatory system had a hard time fighting off. Technically, he died from cardiac arrest—his heart having been weakened from pumping for years against that poundage. He may have died because of obesity, but he didn’t die of obesity. Does it matter?

In principle, I resist semantic solutions to real problems. Switching labels is cheap and changes nothing. (Training people to eschew the word retarded doesn’t make them treat the mentally disabled any better.) But this ruling may have social repercussions that go beyond terminology.

You can bring disease on yourself, of course, like smoking-related lung cancer. Yet designating a state of being as an illness has a subtle distancing effect. It gently suggests that this turn of events is due either to outside forces or to weaknesses inherent in the body that are beyond your control. The AMA’s deeming alcoholism a disease in 1956 has encouraged some alcoholics to embrace Alcoholics Anonymous’ total abstinence and to recite at meetings, “I am an alcoholic,” not “I was.” For alcoholism is apparently not something you get rid of but something you have.

If the AMA’s ruling encourages insurance companies to cover bariatric surgery, swell. But there is no perfect cure, and the one enduringly effective therapy out there is the exercise of personal responsibility. (No, I will not buy potato chips.) Medicalizing the condition actually undermines personal responsibility by turning something you get rid of into something you chronically have. And even then, the overweight cannot embrace the alcoholic’s total abstinence. We all have to eat, and so, barring removing part of your stomach, we all have to make choices about what and how much.

At the same time, the word disease is also unambiguously negative. Thus this AMA decision pushes back against the growing movement that maintains we can be “healthy at any size.” It defies the big-is-beautiful lobby, which sees “fat-ism” at the last acceptable prejudice and as the imposition of a subjective, arbitrary, literally narrow aesthetic in the deceitful guise of concern for health (a credible charge, actually). The AMA has spoken loud and clear: beyond a certain point, carrying large amounts of weight, as Webster’s defines diseases, “impairs normal functioning.” The AMA is therefore guilty of—a phrase I find mysteriously grating—fat shaming.

Since most clinicians don’t think that getting very fat is a health-neutral lifestyle choice, perhaps the AMA’s identifying obesity uncontrovertibly as a problem is for the best. A host of theories now try to explain the worldwide expansion of the waistline, many dovetailing nicely with the disease paradigm: that it is caused by one or more viruses, genetic predisposition, chemicals in the environment, the transformation of the gut microbiome or a marijuana-like acid in seed oils like soy and corn. But we have scads of theories and very few solutions to go with them. Currently, there are no medical cures that improve on willpower. Until there are, it’s best if folks continue to regard obesity as something they can redress, not as something they have.

Shriver’s novels include the New York Times best seller The Post-Birthday World, the international best seller We Need to Talk About Kevin and most recently Big Brother. The views expressed are solely her own.

this is america in 2013. taking personal responsibility went out the window years ago. why should we bother taking responsibility for something when it's so much easier to just blame everything on your parents or your friends or society or mcdonald's or your 3rd grade teacher, etc.?

How do you define disease?...something not good for you..... I've been over weight most of my life. I don't have the usual associated diseases (diabetes, high blood pressure, heart problems, etc.) but I have suffered emotionally. I've never felt attractive and have been treated accordingly. There is a prejudice in the world against people who carry too much fat. Even after all the negative feed back from my environment, I didn't loose weight.Will power doesn't work for me.. When I'm upset, I eat sweets..it's how I cope. So, if you won't accept that there is a physical componet to overeating (chemical imbalance in the brain), then could you concede that this is abnormal behavior, a "mental" disease? The relief I've found is abstaining from the compulsive behavior of overeating, not from food, but from the action of overeating. I do this is by following the 12 Steps of Overeaters Anonymous. WWW.OA.org Adding the spiritual componet (not religious) of "working the steps" is helping me become the person I want to be. Finally, if you've never walked this walk, if you've always been considered "normal", please don't presume you know what goes on inside our heads and bodys. There's much more to this than a "lack of will power".

food environment is one issue, personal responsibility is another :) both are important. and how you model your behavior under these circumstances is paramount. so, yeah, it is difficult to lose weight, it takes hard personal choices, and to make choices means one's responsible. but it is not impossible. those who follow diets and don't lose weight are most probably falling off wagon and not really following anything. they would benefit the most from bariatric surgery (at least for now),

why the need to find a single culprit when it's proven there are many? the idea is we should take everything into account when trying to lose weight, simply blaming obesity on gluttony or on food availability is not gonna solve the problem. first step in my opinion is to ignore nutritional advice :)

I read an article once (I can't find it, but if anyone knows of it, please leave a comment so that it can be properly cited) that found that people who used to be overweight have to consume fewer calories just to maintain their current weight than someone of similar weight, height, and age. For example, if you were to take two, 200 pound men of roughly the same height and age, where one of the men had always been 200 pounds in his adult life and the other used to weigh 230 but lost the weight, the man who used to be heavier must eat fewer calories just to maintain his weight alongside the man who never was any heavier than he is now.

Two things could be going on: 1) The extra 30 pounds damaged the body, or the production of additional fat cells (at some time in the man's youth) make it harder to lose weight after it is gained, and harder to maintain weight after a loss. or 2) The man who was heavier was biologically predisposed to gain more weight (or gain it more easily) than the other man, and has to work harder to lose and harder to maintain.

Yes it is about behavior - it is healthy to acknowledge that. I lost 112 pounds, so I know the behaviors that caused the weight to go on, as well as the behaviors that caused the weight to come off, but it is not just about behavior. I may not be obese any more, and I may be at a healthy BMI, but I know that there is more to my weight than just behavior. Like the alcoholic, I am an over-eater. I do have a weight problem, because I have to work very hard to keep the weight off. I have addressed my weight, but I have not "cured " my weight problem. As is suggested by the study I failed to cite above, while there are several thinks you can DO to make yourself fat of thin, there is also something that overweight people (and formerly overweight people) HAVE that makes them (or helps to keep them) fat.

The authors opinion is not a popular one. Holding anyone accountable for their choices is seldom a popular view these days. Is obesity outside of ones control? Under a vast minority of circumstances. It just so happens that most obese people believe themselves to be under this minority.

How many obese people bust their ass in the gym on a daily basis? How many choose the right foods and eat at the right times? How many have healthy sleep schedules? How many do all of the above? Not many. And I sure as hell would never believe the majority of obese people do all of that work.

I was overweight in high school. Now I run marathons and leave for the Marine Corps in August. A healthy lifestyle is a choice and so is an unhealthy one. Should we start labeling those who have toned abs as individuals with a disease? Didn't think so.

This woman has no idea what causes obesity. There are many reasons why people are obese, lack of willpower is rarely one of them. My brother was thin his entire life until he had to have his thyroid taken out. When I stopped eating gluten (wheat), I, for the first time in my life could say no to eating when not hungry. I lost over a hundred pounds and have kept it off for over 10 years. I didn't lack willpower, I had a medical condition. I don't want to use the word idiot, let's go with this author is, at best, uninformed.

Has it cross the author's mind that maybe people overeating has more to do with more complex factors than simply gluttony. This author is very narrow-minded, overeating is a very complex issue, it ideals with emotions, mood, genetics and many other factors. Many people are dieting and still NOT losing weight. If you are insulin resistant the weight will not come off, this is why 80% of diets fail

@foodandart you wrote in part: "Saying it's more
expensive than fresh (not organic, mind you that's just a marketing scam at
this point) is only true when you don't know *how* to cook, plan and
budget."

Apparently you
have read none of my comments except one that gives you a springboard to
pontificate. I'm sure I eat as well as you and as healthfully after my
extensive study about what foods are best to control cancer and my file of
collected recipes, etc. I eat local,
organic, non GMO, and I eat grass fed and grass finished non drugged meats as
well, same for dairy and eggs. Pesticides and chemical fertilizers are some of
the toxins causing our cancer epidemic, organic, meaning naturally grown, IS
important. Not packaged prepared foods, but fresh and local, not from Mexico.

However I also
know what it costs me in a medium sized town in Idaho to buy at the farmer's
market and the one grocery that carries fresh local food or order by mail
frozen meats etc. I am a single person,
an elderly woman, and my food budget is $200 per month. I decided to subtract my costs of typical
treatment for cancer (which I didn't have), which brings it down a bit but
still it's around $150 per month. This
is just food and higher PH bottled water at $1 a gallon from a geothermal
spring because our city water has too much arsenic and heavy metals and
nitrates from the dairy farms around here to be safe for a cancer patient. My
food budget doubled when I began caring about what I ate as a first against
cancer.

I have relatives
that feed their children on boxed mac and cheese and hot dogs because they
can't afford anything else. That's
cheap, bad food. And what can they do,
they don't have $100 per person per month for groceries.

So I repeat, the
shame of this country is that people with not enough money to eat right, just
can't eat right or feed their children right.
When I see a fat person, I think “there is a person who is poor and
can't find a way to afford to eat properly.”
Sure some of them have no training, schools cutting health and cooking
classes must take part of the blame and using fast food in the lunch room because
it’s cheap is another disgrace. The poor
diet is McDonald's dollar menu, and pasta, lots and lots of cheap white pasta.
Unless they stop with half a cup, it packs on the weight. I suspect you don't
know, in person, any families who must live this way in America. Well, I do and I can tell you that the poorer
one is, the fewer choices they have.

So in America, unlike other parts of the
world, the working poor are obese, as a class. Food Stamps, now called
SNAP? Mine went from $96 per month to
$16 per month in January. Budget Cuts. It buys staples the last week of the
month. I'm old, I don't need new
clothes, own a car, or have a TV or Cable.
I have an Internet connection and a gift netbook. Talking to people like you who have no
concept how the other half lives is my entertainment. This is how I can afford to eat right and
keep my cancer in remission.

I have empathy
and understanding how many families and individuals just can't come up with the
cash to eat good/expensive food, so they eat bad/cheap food. If we really wanted to help cut the cost of
obesity in this country and save the gigantic costs to all of us, we would do
something about that and stop shaming and blaming these people.

Low carb diets were discovered when the Arctic was explored, because Inuits don't have lots of fruits and veggies available. The processed food industry, and GMOs have contributed to the malnutrition now causing disease in America.

Obesity is not caused by overeating or by lack of self control in the same way drug addiction is not caused by taking too many drugs. Certain foods (specifically refined carbs and sugars) act like drugs in our systems, so we need to change our standards of eating: more protein and fat and less fruit and carbs.

Calling obesity a disease is kind of like claiming a sore throat is a unique disease, when it really came from strep throat or mono or yelling. It is more like a symptom.

That said, a lack of self-control can't be the (main) problem with obese people, simply because normal weight regulation requires little self-control. Normal-weight people have no urge to eat beyond the point of satiety. The fact that fat people do, (or gain weight without eating past fullness), indicates *something* weird is going on with their body.

True, someone with rigid self control could ignore their body, but do you really expect anyone to endure pseudo-starvation on a permanent basis? I'm speaking as a skinny person, but I would rather be fat then miserable.

One of the problems with weight is that too many docs, who should know better, can't effectively diagnose and treat things like thyroid/ioding dysfunction, blood sugar regulation, leptin levels, etc. It's really not that complicated. The ancient Egyptians thought the endocrine glands had to be balanced to have a good, healthy life. Duh?

For me, overeating is exactly like smoking. I've been addicted to cigarettes in the past. Now with sweet foods it's almost identical to smoking. It's compulsive and extremely hard to not go for something sweet to make myself feel better.

The worse thing you can do for someone who is trying to lose weight or quit smoking is to say something like, "Just do it. It's no big deal." Why? Because it undermines the person's confidence. The response is, "If it's easy, why can't I do it? Why is it so hard for me?" And they fail and fail and fail. And those around them are very critical when they fail.

Classifying it as a disease removes the burden of failure and the lack of confidence that develops over years of trying and never succeeding. Now the medical community, at least, says "Let's try to fix this together and figure out something that will work" rather than others saying "Just do it. You're a bad person because you're not losing weight."

I am fat. The reason? I eat too much and don't exercise enough. If I watch what I eat and exercise I lose weight. It's not easy to do. There is a great deal of work involved between food shopping, preparing (rather than eating out) the food, and carving out time to exercise. It's loads of work and I can be too lazy to do it. It's much easier to swing by a drive-thru then just sit on the couch because work was rough but it is my fault that I'm fat. There are no other factors involved, period. It's all on me.

It really amazes me how many people refuse to admit what I just did. It is a matter of willpower and discipline. There is no disease involved, nobody is "big boned" and metabolism is a cop-out. You simply have to burn more calories than you take in.

To Lionel Shriver and those of your ilk: I'm 5'5", 240 lbs. I'm not obese and dare you to say it to my face. You'll just be corrected. I know more about my own body than you or anyone else on this planet. Besides, it's none of your business. If you or anyone else won't mind your own business, I'll throw your skinny selves down and sit on you. You watch your own weight. I hope you never have to consider yourself "obese."

Self-control was taken away by the food companies that lace additives into the foods that disengage the sense of fullness when we eat. Just now the report comes out that refined carbohydrates (bread, pasta, rice, refined sugars) cause latent hunger rather than fullness. The US used to be a lean nation. Americans became fat because they lost self control in unison? Do you believe that? An iron-controlling molecule was removed from the American diet when white bread supplanted whole grain bread. That was the first step towards an obese generation. Then obesogens were added to foods like bisphenol A. No, self control was taken away by the food companies to generate more profits. Get the story straight Time Magazine. We're talking about the biggest food purveyors in the world. That is where the blame lies.

I want to voice my opinion on willpower.I am not obese, so this may not directly
translate, but perhaps it will.I have
bipolar disorder that is characterized almost exclusively by near-constant
depression. Bipolar depression presents
identical to major depression.I thought
I was bipolar, doctors thought I had depression.The treatment for depression is extremely
harmful to the bipolar, so I abstained after my first try. I went through 12
years of untreated depression before I got a diagnosis. I tried many things,
adopted many mindsets, but I could not stop being depressed.When I started treatment for bipolar disorder
and took medication specifically for bipolar disorder, I had immediate
improvement.Any major improvements in
my mood were directly tied to new medications and/or dosages.Things that I could not do before despite my
best efforts, like get out of bed when I woke up instead of hours later, not feel
persistent shame, tell myself the future could be good and believe it was
possible, stop thinking about suicide, I could suddenly do with my medication.Within an hour of taking one new medication,
I felt hopeful for the first time in over a decade.Though I put an enormous amount of effort
into improving my mental health, before and after treatment, I credit obtaining
excellent medical care as the most important factor for my health today.I had been told by others and myself that if
I just tried hard enough, I could be happy. It infuriates me now. I have a neurological
disorder; don’t tell me it’s up to me to smile it away.It’s insulting and ignorant. It is like
telling an epileptic to try really hard to not have a seizure.

Science has proven that there are changes that occur in the body
when enough weight is gained that make it difficult to lose weight. Those changes
can be passed on for generations.I
think there are people who are unable to change their obesity by
themselves.Some people can; there are
many success stories.Treating obesity
may be difficult and the treatment that works for one person may not work for
another.

One area I think willpower can come into play with weight is
deciding to lose weight when you are overweight but not yet obese. I was about
40 pounds overweight (5’8”) and my husband was 30 pounds overweight
(5’7”).We could have continued to gain
weight, but we both decided that we should stop while we’re ahead.We changed our diets substantially.We eliminated different things: I took out
sweets like candy and soda and he took out fast-food and fatty snacks like
chips. We had gorged on them.Taking them
out and doing moderate exercise helped us lose our weight.I saw my mom, dad, uncle, and brother do the same thing.We got overweight, realized we were out of
control, stopped and lost it.I have many
more relatives who did not change their diets or up their activity, and they
are obese today.Some are wheelchair
bound, tied to oxygen tanks, and many have weight-related diseases and
disorders. Some have died for
obesity-related causes.

I could sit here and say it’s a matter of willpower for obesity because when I was overweight, I lost 23% of my body weight through self-directed
behavior modification.That hardly seems
helpful, because science is demonstrating there are weight thresholds that must
be crossed to turn on the negative physiological and genetic changes.Similarly, some obese people may have been
able to lose the weight themselves, but their circumstances may differ from the
rest.Mobility, illnesses, and support
systems are all huge factors for weight loss.There are many more. To disregard the evidence that shows there are barriers
in weight loss is insulting and ignorant.

**I will note that I was not able to lose weight while
depressed, nor do I think I could if I were depressed in the future. I believe mental health is a deciding factor
in combatting obesity.

Weight is genetics. Yes, there are people who overeat. There are people who eat nothing but junk. There are people addicted to food. But, whether you weigh 105 lbs or 500 lbs depends on how your body processes food. I'm a vegetarian, I never eat junk food or fast food. I haven't had pasta in years. I eat small, low calorie meals throughout the day as prescribed by a nutritionist. And I spend 90 mins at the gym 3-4 times a week. But, I'm 5'6" and weigh 290 lbs... and gaining. My brother on the other hand, eats nothing but junk food and lives on Big Macs. His idea of exercise is watching fishing on television. And he's 6' 2" and 175 lbs. It's the magic of genetics! So all I'll saying... don't just assume that is someone is obese, it's because they lack will power.

I caught this bit after my last post.WILLPOWER.What is L. Shriver talking
about?Someone needs to do more research
and keep up to date on this subject.Research has found at least three triggers in the body designed not to
let you starve to death.The stomach has
a brain that sends signals when you are not eating enough calories.The liver has another trigger that tells you
to eat and the muscles have a similar trigger that does the same thing.How many of you could stay away 24/7.Very few, the rest of us will become psychotic,
hallucinate and then black out.What
makes anyone think that one of the most important survival body functions such as
eating would be any different?Is it poor
will power to suffer dehydration when you dont drink water, is blacking out from lack of sleep a lack of
will power?NO, and neither is braking a
diet.

The body
has one primary goal, to perpetuate its DNA.To survive.Both personally as
well as the survival of the species.

The body
doesn’t understand the need to fit into that little red dress, it only knows
that you have cut your eating . It will do whatever it has to, to prevent hunger, starvation and death.

@michellerouge For more info., you can Google Dr. Mercola and Dr. Brownstein for their takes on this. In this New Digital Age, the information is there for all, and you can do your own critical thinking.

@narwagner Have you tried slowly changing sweet for fat? I did it by allowing myself to have one small fatty thing instead of a sweet. Instead of a pint of ice cream (Ben & Jerry's 16 oz. 'single-serving size!! - whoop!! NO!), I went to a farmer's market and got a half-pound of slab bacon and cook up a few thick strips.. Just heaven and it is SO much a better *ding!* when the craving for a treat hits.. I also take one of those Josephs Flax seed pocket breads, cut in half, put a thin smear of peanut butter (REAL peanut butter the kind that's just peanuts and oil and you have to put in the fridge after you open it or it separates - NO SKIPPY or JIF!! - that's disgusting stuff) and make a PB & bacon sandwich.. it hits the spot and the bacon with the salt from the nuts.. oooohh.

@spookiewriter You had to have seen my comment. I don't care that you are fat and why. That's "your" business. I have my own business. I'd still like you fat if I knew you. I'm not hung up on outward appearances like many in today's society. But, when you do lose weight, do something about that bobblehead you are going to get. You still won't look right. My size is none of anyone's concern. But, if you really have to know, I'll let you speak with my physician.

What I would like to know is, What about "Mind your own business." don't a lot of folk, esp. the fat police, don't understand? They should try it some time. They should just take it a moment at a time and a day at a time. Practice minding your own business and you'll be a much happier person, fat and all. I guarantee it.

@PamJohnson There are two meanings for the word "obese" -- one is "extremely fat" and the other is having a BMI of 30 or over. The latter is the medical definition of obesity, not what people say to put people down.

I lost 50lbs on freaking Wendy's. Not the healthiest by any notion (mostly too high on sodium), but if you keep passing on the blame to these easily blamable third party (oh look big evil corporations are at fault for poisoning our food), well good luck getting anything done.

And no americans didn't become fat in unison. There are lot of lean and fit americans out there. It's just that larger portion of the population is getting fatter because of the change in lifestyle in both activity and eating habbit are supportive towards that kind of body type.

@OtisDog Thank you for this thoughtful and sharing post. So important that you say just because you did something with determination doesn't mean everyone can. I thought this was a great comment with much empathy. I think you should be very proud of your accomplishments, congrats on your correct diagnosis and best of luck as you move forward in your life.

My point is that the way your body processes food has nothing to do with will power, and everything to do with your DNA. And assuming someone is obese simply because of lack of willpower is an oversimplification of a very complex issue.

@kidthings33 You are missing the whole point of the article because you believe you're the exception - maybe you are, but I don't believe the author is naive enough to say there aren't very rare exceptions to the idea that generally if you really want to lose weight you can and will primarily through changes in diet and exercise. If you focus on the rare exception, you leave the vast majority of those who suffer the "disease" of obesity justified in saying, "see there's nothing I can do about it so why try (harder)?" The vast majority of obese people can lose weight with proper exercise, eating habits and proper rest - it's really that simple - why complicate the solution for the majority of people by focusing on a rare exception?

It talks about how the hormone levels of people on a calorie restriction diet changed during and after their diet. The two hormones assessed were leptin (which suppresses appetite and helps to regulate metabolism) and ghrelin (which stimulates hunger). The weight loss triggered a decrease in leptin, which translated to a slower metabolism and a decreased ability to regulate food intake (or even to be aware that one is full). At the same time, participants saw an increase in ghrelin.

So as they were reducing calories, hormones were stimulating hunger signals, slowing their metabolism, and giving them weak or inappropriate "stop signals" even after they had eaten. Two of the things that the study found was that 1) The decrease in leptin was disproportionate to weight loss. A 10% loss in body weight resulted in a more than 60% decrease in leptin, and 2) the changed hormone levels persisted for a year after the initial weight loss. which may help to explain why most of the subjects in the study gained about half their weight back.

I do equate obesity with alcoholism. I do believe that alcoholism is a disease that is often brought on by some biological trigger. You can adjust your behavior, you can overcome it, but it is not about behavior alone. Treating it as a chronic condition does not lie to the alcoholic. It does not absolve them of their behavior. It it tells them that they will always have a problem with alcohol and they will always need to address the problem. The statement of those in AA that they are alcoholics requires them to constantly acknowledge their problem with alcohol and to address it. They do not shirk their responsibility for their behaviors because of "they have a disease", they admit that they have a problem and embrace the idea that it is something that they will always have to treat. AA is not a cure, but it is a treatment - and it is one that works.

The medical community didn't lie to alcoholics in order to make them feel better. Why do you think that's what it is doing so with people who are overweight? Why should the obese not be afforded the same chance to treatment as the alcoholic?

@timfey@kidthings33 Well, in the end, I see your point because I never saw a fat person in a concentration camp. However, for the rest of us there are roadblocks along the way, like immobility from injury, poor thyroid management, side effects of medications, and the logistics of eating in a family and in social settings.

@KatrinaDulce@theOracleThanks for the article. I have a special doctor for endocrinology at the Holtorf clinic, who knows about leptin and ghrelin. I had to go there after two endocrinologists nearly killed me here in the Coachella Valley (Palm Springs and Othe Desert Cities).

My thyroid is sitting in a jar somewhere in Pasadena, not in my neck. So my hormones are not easy to regulate. I would be interested in what you did for your diet, etc., if you would tell me.

I had a friend in med school who was actually able to keep up with the NEJM. Most docs can't. She told me she would stack them next to the toilet, and ...it works! lol